Healthcare Insurance
Claim case sharing
Actual hospital accommodation exceeding the “Room and Board Benefit” of medical insurance
Mr. Lam was advised by his attending doctor to have a gastroscopy in a private hospital. Thinking that his medical insurance would cover most of his hospitalisation expenses (the maximum Room and Board benefit of Mr. Lam's medical plan was HK$1,580 per day), instead of staying at a semi-private room (HK$1,300 per day), Mr. Lam decided to stay in a private room (HK$2,800 per day) to enjoy a more comfortable environment at the expense of paying a bit more.
Mr. Lam was hospitalised for two days. He filed his insurance claim immediately after being discharged, expecting to get back most of his hospitalisation expenses of HK$32,320. However, Mr. Lam was only reimbursed HK$18,238, broken down as follows:
Items |
Maximum Benefits
|
Actual Expenses
|
Mr Lam’s
|
| Room and Board | $1,580/day | $5,600 ($2,800 x 2 days) |
$3,160 |
| Miscellaneous Hospital Charges | Full Cover | $10,000 | $10,000 |
| Physician Fee | $1,580/day | $5,000 ($2,500 x 2 days) |
$3,160 |
| Surgeon Fee | Up to $260,000 according to Surgical Schedule |
$16,000 | $16,000 |
| Total | $36,600 | $32,320 |
Why was the actual claim settlement far less than Mr. Lam expected?
In Hong Kong, surgeons' fees and hospital charges vary by the type of accommodation a patient opts for. The billed amount increases as the level of accommodation chosen changes from ward to semi-private to private. If Mr. Lam had stayed in a semi-private room, the actual expenses incurred would not have been as high as HK$36,600. Therefore, most medical insurance companies in the market have a provision stating that if an insured person opts for hospital accommodation exceeding the “Room and Board” entitlement stated in the table of benefits, the amount payable for Hospital Treatment and Services will be adjusted proportionately based on defined factors.
Some medical insurance plans will adjust according to the following factor:
Daily rate of Room and Board entitlement / Actual daily rate of Hospital accommodation incurred x 100%
Therefore, the claim amount that Mr. Lam was entitled to was HK$18,238
[i.e. HK$32,320 x (HK$1,580 / HK$2,800) x 100%].
In order to ensure that hospitalisation expenses fall within customers' expectations, they are advised to choose a medical insurance plan incorporating their desired level of accommodation and stick to the Room and Board Benefits they are entitled to.
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